Self-retaining cul-de-sac retractor



1954 R. J. GLENNER SELF-RETAINING CUL-DE-SAC RETRACTOR 2 Sheets-Sheet 1Filed July 5, 1952 INVENTOR. rzifisvz/zer Jan. 19, 1954 R. J. GLENNER2,666,428

SELF-RETAINING CUL-DE-SAC RETRACTOR Filed July 5, 1952 .2 Sheets-Sheet 2IN VEN TOR.

I1 I A I Patented Jan. 19, 1954 UNITED STATES PATENT OFFICESELF-RETAININ G CUL-DE-SAC RETRACTOR Robert J. Glcnner, Chicago, Ill.

Application July 3, 1952, Serial N 0. 297,022

2 Claims.

having right angularly bent blades and equipped with heretofore knownshape and weight characteristics has thus required considerable physicaleffort and attention, appropriating both hands of one of the operativeattendants or assistants until the vaginal wall is closed.

In order to make the necessary field availability for the operatingsurgeon, retraction of the vaginal walls is required both anteriorly andposteriorly as well as bilaterally. Four hands are thereby tied up inthe performance of retraction so that serving of their usual tasks bythe assistants who do retraction such as sponging, placing of sutures,etc., under such circumstances may not be had. Surgical implementationby such assistance is frequently of great importance to the surgeon butbecause availability of further help is ruled out by the inherent spacelimitations which surround the operative field, it is now proposed torelieve to a partial degree at least, the manual demands which have beenimposed by retraction.

A principal object of the present invention, 1

therefore, is to achieve a self-retentive characteristic in posteriorlyapplied retractors to cause them to remain in the placed position sothat intermittently or occasionally an operative assistant when requiredto do so, may release his hold therefrom to do another function orassistance without incurring the risk that such retractor will meanwhilebecome expelled or dislodged from its placement.

Another object of the present invention is one of providing initially aposterior placement vaginal retractor which, following the peritonealpenetration, may be made to serve the consequent purpose of retractingthe vaginal mucosa and the incised posterior peritoneum by thesimpleexpedient of further insertion and without requiring relaxation from itsoriginal placement in order to gain entry into the cul-de-sac.

- Further and additional objects of this invention are such as willbecome more evident during 2 the course of the following detaileddescription and explanation.

For a better understanding of the principles and methods of operationwhich underlie this invention, reference will now be had to theaccompanying drawings, and to the following detailed description, inboth of which like reference numerals designate corresponding partsthroughout, and in which: v

Fig. 1 is a median sectional side view through the uterus and adjacentareas in which posterior and anterior incisions of hysterectomy havebeen made into the vaginal mucosa and illustrating retractors distendingthe cul-de-sac and vaginal vault preparatory to the making of thelateral incisions.

Fig. 2 is an enlarged perspective view of the upper portion of a vaginalretractor embodying therein certain principles of the present invention.

Fig. 3 is a side elevational view of the entire retractor with portionsbroken away to reveal interior construction thereof. v

Fig. 4 is a front elevational view of an instrument similar to the oneillustrated in Fig. 3.

Fig. 5 is a fragmentary inverted plan view of a portion of modifiedretractor instrument embodying certain principles of the invention, and

Fig. 6 is a sideelevational view of a retractor embodying certain of thefeatures illustrated in Fig. 5.

When removal of the uterus through the vagina is indicated, a patient isprepared antiseptically and supported on a lithotomy table preferably inthe Trendelenburg position. A weighted vaginal speculum I3 ispendulously hung from the posterior lip and as a consequence there isexerted in this direction an initial influence of vaginal retraction.Normally this exposes sufiicient visualization as well as access topermit the cervix to be seized by means of tenacula H1 or forceps andbrought down.

From this point on, operative techniques differ in respect'to theincisional sequences. In some instances, the posterior vaginal. mucosais incised ahead of the anterior wall. Other surgeons follow a reverseorder. However the progress ofthe operation may be in respect to thisphase of procedure, the function of a selfretentive retractor is equallyimportant as re-, gards the several advantages which will now bediscussed.

In order to establish the required field clearance for the making ofadequate transverse incisions as well as thereafter for making of the 3lateral incisions, the vaginal perimeter is distended by a series oftools as follows: anteriorly by a right angle, thin bladed, retractor lI, Fig. 1, which is first inserted to a limited distance somewhat lessthan that in which it is shown in Fig. 1.

Laterally, the vaginal passageway is distended by opposed curved bladeretractors (not shown) fashioned with right and left side handles sothat they may be grasped at close range. A narrow bladed retract'or i4is lodged against the posterior vaginal wall and urged in opposition tothe anterior instrument I 1. One operative as-' sistant grasps theanterior retractor in one hand and one of the lateral retractors in theother, and the other assistant grasps the remaining retractors inreverse manner. This practice permits the assistants to stand with theirbodies well away from the operating surgeons position which is that ofseating located at the center of the oper-ating'table end. Multiple spotlighting at inclined angles which fianl: the position of the operatorserves to illuminate the field for thorough visualization.

The force exerted in the posterior direction by the speculum i3 issupplemented by means of a posterior retractor is designed so as to havea narrow bladed characteristic of about the same order as the anteriorretractor H but preferably formed as by forging or bonding with a pouchor hull-like protuberant portion l5 preferably made of solid metal,whereby to contribute a predominant weight and mass factor at this endof the instrumentin contrast with the hollow handle portion 16, Figs. 3and 4, which is permitted to gravitate pendulously within the central.channel of the. Weighted sections of the speculum.

In the preferred embodiment of design which has been illustrated inFigs. 1 through 4, the

part of the wedge or sloping surface l8. a shallow bulbous enlargementl9. This constitutes the largest girth of the blade and is designed inorder to avail of the constricting muscular efifects surrounding theposterior incision with the 0biect of assisting the retentive qualitiesof the retractor when placed into the position in which it appears inFig. l.

The nose portion H which has been described as an entering wedge may besaid to resemble an inverted duck bill. In the preferred design its topsurface 23 has been indicated as sloping curvedly downward of thetangential surface 24. This variation is of secondary importance havingas its purpose to facilitate a descending movement to the blade and tooppose somewhat the displacing effect of the wedge slope l8.

From the foregoing it is to be understood that retractors l i and M areboth utilized in two-position placements, one before its adjacent wallhas been entered and the other following such penetration. In the caseof the posterior tool l4, however, gravity may be utilized to give bothof its placements the quality of self-rctentiveness or stability inorder to release for other. duties a hand of one of the assistantsotherwise necessarily devoted to retraction exclusively. This reliefinvolves much more than mere economy for the entire theater of activitywhere such a surgical operation is conducted is crowded on account ofthe occupation by the surgeon and the two assistants.

With but three pairs of hands available to conduct all of the variousfunctions which are required in a panhysterectomy, the liberation ofone. hand from retraction even for brief intervals of time affords muchneeded surgical assistance. With the freed hand, one assistant may nowbe available for applying clamps, making sutures, sponging away blood inorder to clear the field for observation, etc. Without self-retentionwhen an assistant released his I hold of a, retractor to devote himselfto the execution of an assist function, the relaxation of his hold of aconventional retractor resulted invariably in a bodily dislodgementthereof with following ejection. 'Falling to: the floor constitutes acontamination of the tool and requires replacement by a properlysterilized substitute. In contemplation of such. mishaps, pluralities ofretractors have had to be prepared in readiness for substitution.

Having to replace the posterior retractor during the peritoneal incisionmay involve critical loss of time, as well as require realignment ofaccompiished procedures, such as partially ligated blood vessel stumpsand ligaments. A secure and yet comfortable retention of an adequate andeffective. retraction. will, for manifest. reasons, reduce variouselements of surgical risk in these classes of operation. The proposedretractor is significantly shaped and weighted at its insertableextremity or blade portion and in over-all respects proportioned afterthe manner of the examples illustrated in. Figs. 3; through 6. The totaleffect of this improved design achieves security of placement andretention on a materially improved level. By constructing thisinstrument so that the preponderance of its mass and weight is locatedinthe blade portionv and by shaping this portion after themanner of abulbous ships hull, an. eflicient retractive performance is had uponwhich the surgeon may confidently rely without sacrificing preciousvspace or impairing access.

The muscular elasticity inherent in the incised vaginal wall is utilizedto constrictively encompass the bulbous under-belly of the retra'ctorblade preferably at a region just in front of its largest swell portioni9.

In Figs. 5 and 6, a modified swell has been incorporated by reason ofwhich the blade is made self-retentive on account of its sideward ovateshape. 25 in. combination with a terminating bulbous swell of. minorsignificance. In this case dislodgement is, resisted b the weightedseating of swell, 2.! as'well as by the constricting effect of theincision boundary working against the ovate hull. In this. embodimentan. entering wedge. has been omitted although its.mcorporation ispractically combinable if desired. Thus, self-retentiveness respectingsurgical fixtures is obtained from cavity seating shapes combined isproposed that a large acute angle which preferably may correspond withthe inclination from normal inherent in the Trendelenburg position, beestablished between the blade and its shank. Thus as viewed in Fig. 1,the handle rod 22 hangs perpendicular when the inserted portion islodged in either of its placements before or after penetration of thevaginal wall.

When the instrument is thus disposed and hung over the insert hook ofthe weighted speculum it will be found to obtain a natural weightbalance slightly favoring the blade portion. This is further conduciveto stability and retention of placement and less susceptible to changein angle. The attainment of this preponderance of weight is achieved bymaking the belly portion l5 solid while at the same time making thehandle portion l6 throughout hollow, after the manufacturing techniquesof tableware and similar articles. This makes it feasible to produce asmooth, all metal integral fixture, easy to sterilize, polish, andotherwise maintain in conformity with high standards of operating roomhygiene.

The stem and handle sections require to be made of continuous contourand seamless metal components free of crevices or recesses. Aftersterilization, all surgical instruments including retractors, requiredto possess physical characteristics whereby they may be securely held bya glove encased hand as against influences which are conducive toslipping. For this reason, the handle portion I6 is advantageouslyconstructed so that it has a substantial palm-fitting size and shape. Onthis account such tools would ordinarilypossess a greater preponderanceof weight at the handle than in the blade. The hollowing out of thehandle l6 and the shank 22 and the weight loading in the blade thereforeachieves a radical departure in weight distribution with regard tosurgical retractors consistent with a unitary construction free ofcrypts, crevices or internal recesses which would present problemsrespecting sterilization.

When the vaginal wall is to be closed, the lifting and removal of theimproved posterior incision retractor is attended with the same ease andmanipulative convenience as that which characterized the conventionalthin bladed types of instruments. In keeping with this objective, alltapering or sloping surfaces are throughout rounded and so sloped as tohave gradual convergence and but shallow protuberance. It is to beobserved that the top of the instrument is substantially fiat, the sameas in the case of flat bladed retractors. This permits the blade torepose well out of the way so as not to interfere with the freedom ofmanipulation in the limited space within which the surgeon requires todo a number of procedures while working against time. The sameinstrument which is thus capable of eflicient self-retention is made toserve the dual functions of initial vaginal wall vault retraction andthereafter to be advanced into the cul-de-sac to retract both thevaginal wall and vault concurrently.

While the present invention has been explained and described withreference to illustrated examples of embodiment, it will be understoodnevertheless that various modifications and variations may be madeWithout departing from its essential spirit or scope. Accordingly it isnot intended to be limited by the precise language employed in theforegoing detailed specification nor by the features of the accompanyingillustrations, except as indicated in hereunto appended claims.

The invention claimed is:

1. A vaginal wall and cul-de-sac retractor comprising an integralmetallic instrument having a shank portion flaring at one of its endsinto a, curved fiat neck portion, an angularly disposed blade joinedwith said flat neck portion, said blade having a substantially fiatouter surface constituting a tangential continuation of thecorresponding surface of said curved fiat neck portion and a pouch-likeprotuberant under surface opposed to its said outer surface, thelongitudinal contour of said pouch-like under surface including anentering wedge end flare merging into a maximum swell and thendiminishing elliptically, and a hollow palm-fitting handle at the otherend of said shank portion.

2. A dual placement retractor for vaginal hysterectomy comprising, anintegral instrument having a shank portion adapted to be pendulouslysupported in a vertical position, a bulbous weighted blade portiondisposed at oblique angularity with said shank portion, said blade andshank portions being connected by a curved fiat neck portion, apalm-fitting handle carried at the lower extremity of said shank portionhaving a greater volume dimension than said bulbous weighted bladeportion but having a hollow interior cavity so as to afford a lesserweight resolution than that of said blade portion, whereby retention ofthe blade portion during both preincision and post-incision placement inrespect to the vaginal mucosa is thereby gravitationally resolved forovercoming sphincteral ejection.

ROBERT J. GLENNER.

References Cited in the file of this patent UNITED STATES PATENTS NameDate Damron Dec. 2, 1930 OTHER REFERENCES Number

